September 19, 2016

The clinician community—anesthesiologists and nurse anesthetists included—breathed at least a partial sigh of relief last week.  The Centers for Medicare and Medicaid Services (CMS) announced that clinicians would not suffer financial penalties in 2019 based on their performance in 2017 under the new Quality Payment Program (QPP) that implements the Medicare Access and CHIP Reauthorization Act (MACRA).

Still, the message is clear: CMS intends for all eligible clinicians to participate in the QPP as the way to avoid negative payment adjustments down the road.  It is simply providing some leeway and choices in the pace with which clinicians make the transition during the program’s first year.  

The only anesthesiologists and CRNAs that will not have to report something in 2017 to avoid penalties (exacted in 2019) are brand-new ones, those with fewer than 100 patients or less than $10,000 in billings or those in an advanced Alternative Payment Model (APM).

As Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform says in HealthLeaders, “This is not delaying implementation of MACRA, it’s actually creating a less problematic starting point for the measurement that will go into determining what happens to physicians in 2019.”

Message:  Keep moving.  However, keep in mind that the final rule could contain significant changes when it is issued in November 2016. 

The announcement from CMS comes in response to widespread concerns from clinicians and medical associations about the proposed rule’s aggressive timeframe, complexity, stringent reporting requirements and failure to consider the special needs of practices with fewer resources, including physicians in rural communities.  In a September 8, 2016 blog post, CMS Acting Administrator Andy Slavitt outlined four options for clinicians that will ease the transition by allowing them to “pick their pace for participation” during the first reporting period that begins on January 1, 2017.

All four options enable clinicians to avoid penalties in the first year as they move to a reimbursement model based on value and quality; some offer an opportunity for positive payment adjustments.  The point is that these choices give anesthesia providers an opportunity to start relatively slowly or move ahead more ambitiously, based on how far along they are in preparing for MACRA. 

How Fast Do You Want to Go?

Everyone is on the same journey; it’s up to you and your practice to decide how quickly you want to start off on the trek.  Be aware, however, that clinicians and practices will have to wait until CMS provides more information (which it has promised to do when it issues the final rule in November) to make a final decision on which path to take.  Though details are forthcoming, the four options are: 

1. For clinicians participating in the Merit-Based Incentive Payment System (MIPS):  Report “some” information to the QPP that includes data collected after January 1, 2017.  This option would allow you to test the water, assess how well your system is working and gear up for more extensive participation in 2018 and 2019 as details about the QPP unfold. 
2. Report complete data for a reduced period in 2017.  This option would enable you to report for part of the calendar year (not necessarily beginning January 1, 2017) on quality measures, use of technology and performance improvement activities, and not only avoid a penalty, but also potentially earn a partial positive payment adjustment in 2019.
3. Report for the entire calendar year.  If you are ready to go, you can report quality measures, technology use and improvement activities for the full year, and potentially receive a modest payment increase.  According to CMS, this is not out of the realm of possibility; practices of all sizes have already attempted and succeeded in submitting a full year’s worth of quality data.  If you are confident about your system and procedures, you might want to move ahead with this option and aim for the bonus. 
4. Participate in an advanced APM.  The proposed rule allows clinicians to participate in an advanced APM, such as Medicare Shared Savings Track 2 or 3 in 2017.  Practices that receive enough of their Medicare payments through an advanced APM would quality for a five percent payment incentive in 2019. 

Our assessment is that most ABC clients probably will want to consider option 2, full reporting on all measures for part of the year, or option 3, full reporting on all measures for the entire year.  The advanced APM option will become more relevant in anesthesiology if programs like the Perioperative Surgical Home become an APM, which we hope will be available in the not too distant future.  However, anesthesia providers should not rule out the possibility of participating in an APM sooner.  These are most likely to be found where there are large academic medical centers or other sizable anesthesia groups that are already on the road to integration with their institutions.

One of the more frustrating aspects of deciding which path to take is the fact that CMS quality measures will not be decided until the second quarter of 2017.  This means that practices will not have quality data on approved CMS measures for the entire first quarter of 2017. 

Still, CMS’s decision to give clinicians a bit more breathing room with regard to MACRA implementation bodes well for the QPP.  In summarizing the extensive feedback CMS received from physicians in response to the proposed rule, introduced this past April (and summarized in our eAlerts on May 2 and May 9, 2016), Slavitt notes that “the clinician community wants a system that begins and ends with what’s right for the patient.  We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians.”

Overall, the clinician community is pleased with CMS’s responsiveness to its concerns.  "By adopting this thoughtful and flexible approach, the Administration is encouraging a successful transition to the new law by offering physicians options for participating in MACRA,” says Andrew Gurman, MD, president of the American Medical Association.  “This approach better reflects the diversity of medical practices throughout the country.  The AMA believes the actions that the Administration announced today will help give physicians a fair shot in the first year of MACRA implementation.  This is the flexibility that physicians were seeking all along, and we are looking forward to working with Acting Administrator Slavitt and the administration on other efforts to get MACRA off to a successful start."

The American Society of Anesthesiologists praises CMS for recognizing that physicians need more time to prepare for the new payment system.  The ASA had advocated for a delay in implementation until at least July 1, 2017, arguing that the January 1 deadline would not give physicians and facilities enough time to establish the procedures and systems needed to begin collecting performance data.  The ASA sent detailed comments regarding the proposed rule in a June 27, 2016 letter to CMS. 

MACRA Basics Revisited

As discussed in our February 8, 2016 eAlert on MACRA fundamentals, MACRA provides two tracks for participating clinicians:  MIPS and advanced APMs, which include accountable care organizations, bundled payment models and other structures that tie clinician reimbursements to patient outcomes.  The goal of MIPS is to prepare clinicians for participation in an advanced APM.  The vast majority of clinicians will participate in MIPS in the first year.  Only about four to 11 percent of clinicians currently qualify for participation in advanced APMs, according to a Brookings Institution report, How the Money Flows Under MACRA.

Participants in MIPS will receive a composite scored based on their performance in four areas:

1. Quality (50 percent of score in year 1, 30 percent of score in year 3):  Clinicians would report at least six measures versus the nine measures under the Physician Quality Reporting System (PQRS).  These measures will be included in the final rule.  MIPS eligible clinicians may select their quality measures from a list of all measures or from a list of measures specific to their specialty. 

CMS has proposed an Anesthesiology Specialty-Specific Measure Set for physician anesthesiologists.

• MIPS #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
• MIPS #76: Prevention of CVC-Related Bloodstream Infections*
• MIPS #404: Anesthesiology Smoking Abstinence*
• MIPS #424: Perioperative Temperature Management*
• MIPS #426: Post-Anesthetic Transfer of Care Measure: Procedure Room to PACU*
• MIPS #427: Post-Anesthetic Transfer of Care Measure: Procedure Room to ICU*
• MIPS #430: Prevention of PONV - Combination Therapy*
  *designates a proposed "high priority measure"

2. Cost (10 percent, 30 percent):  Cost is measured on a claims basis; thus, no reporting is necessary.

3. Clinical practice improvement activity (15 percent, 15 percent):  This new category consists of process improvement activities in nine areas, each of which is scored on an “all or nothing” basis.  These include activities such as care coordination, patient safety and beneficiary engagement, such as the creation of care plans for patients with complex medical needs.  Clinicians can choose to report on activities that reflect their practices’ goals.  Since clinical practice improvement activities were not a part of the PQRS, we recommend reviewing this list to see which activities you are already doing or planning to implement.  

4.  Advancing care information (25 percent, 25 percent):  This category replaces the Meaningful Use Electronic Health Record Incentive Program.  Clinicians would report measures that show how they use EHRs in their daily practice with an emphasis on interoperability and health information exchange. 

The 100-point composite score across these four categories is used to determine a positive or negative payment adjustment.  The criteria for determining incentive payments or penalties will be adjusted each year based on the country’s performance as a whole.  The better the performance, the lower the incentive, because the program will remain budget neutral.

For More Information

The ASA offers a variety of MACRA resources on its website, including descriptions of the MIPS components and a short list of MACRA acronyms.

CMS also provides extensive MACRA resources, including fact sheets and links to webinars.

An excellent infographic and introduction to MACRA can be found here. 

For more information, also see the Medscape article MACRA for Busy Docs:  12 Things to Know.

We are monitoring this issue closely and will keep you informed of new developments as they arise.  If you have any questions, please contact your ABC client service executive.

With best wishes,

Tony Mira
President and CEO